THE ADOPTION OF PDAS WITHIN THE HEALTH CARE SECTOR: IMPROVING WORK PRACTICES AND SERVICE DELIVERY IN AMBULATORY CARE
Joan Cooper, Carole Alcock, Lois Burgess Faculty of Informatics University of Wollongong NSW Australia
[email protected] [email protected] [email protected]
ABSTRACT The adoption of PDAs (Personal Digital Assistants) with mobile communication capability has the potential to improve work practice and efficiency in the health care sector. Ambulatory care workers, particularly, might welcome the prospect of point of care availability and capture of client information. A key factor in the lack of adoption of such systems, is that traditionally, health care information systems have been designed for desktop computing, whereas many healthcare workers are highly mobile. It is expected that new technologies of hand-held devices will change this. This paper outlines work in progress towards the development of a PDA based point of care e-health solution. The introduction of an ambulatory care information system (ACIS) is part of this project. A detailed outline of the proposed research is provided. Initial stages of the research have included a detailed workflow analyisis - an essential first step in the integration of work practices with PDA applications.
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1. INTRODUCTION The adoption of PDAs (Personal Digital Assistants) with mobile communication capability has the potential to improve work practice and efficiency in the health care sector. Ambulatory care workers, particularly, might welcome the prospect of point of care availability and capture of client information. A key factor in the lack of adoption of such systems, is that traditionally, health care information systems have been designed for desktop computing, whereas many healthcare workers are highly mobile. It is expected that new technologies of hand-held devices will change this. This paper outlines work in progress towards the development of a PDA based point of care e-health solution. The aim of this project is to carry out fundamental R&D on the effective delivery of healthcare services to point-of-care using e-Health solutions for ambulatory care services. The outcomes of the research will be used to design and build a prototype personal digital assistant (PDA) based delivery system that utilises generic, reusable and scalable components. A PDA based point-of-care system is significant as it provide for collection, delivery and exchange of timely information (both text and images) at the point-of-care leading to a more efficient health care system. The expected outcomes of the research include: •
Production of detailed workflow diagrams through analysis of workflows in Ambulatory Care Services.
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Knowledge of, and solutions to, work practice issues associated with the implementation of PDAs in mobile healthcare situations.
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Development of a suite of middleware applications for interface software suitable for point-ofcare access to databases, knowledge-repositories and directories.
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Development of generic, scalable and re-usable object oriented software components that are easily transferable to similar healthcare applications and compatable with CHIME (Community Health Information Management Enterprise) (Britt & Miller, 1997).
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Development of a security, authentication and privacy framework (including policies and procedures) for ambulatory care information systems (ACIS).
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Demonstrate that computer-based information (both text and images) capture and retrieval can be integrated into point-of-care practice.
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Integration of work practice issues, scalable software and security protocols into a successful prototype PDA based healthcare delivery system.
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Accurate, relevant and timely access to patient management information by GPs.
2. BACKGROUND Effective healthcare delivery within community based health services depends on efficient information access (NSW Health Information Management and IT Strategic Plan, 2001). Current systems are paper based and are limited to what the healthcare worker can effectively carry. The proposed PDA based point-of-care (POC) system will provide for collection, delivery and exchange of timely information at point of care. The key advantages of such a system will be its high mobility and flexibility in matching complex healthcare workflow requirements as well as immediate updating of healthcare records. While the prototype will provide an immediate solution to the problem of improving workflow and work processes within Ambulatory Care Services, and at the same time deliver more efficient healthcare, this project will also produce reusable and scalable software components that enable Ambulatory Care Services to have an application that is technology
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independent. This will allow new technologies to be “plugged in” as they become available enabling other mobile healthcare community workers to utilize the components for applications of PDAs at POC. The philosophy of Ambulatory Care is based on providing patients with a choice of treatment in their own homes (Hospital in the Home) or other locations as an alternative to hospital. In Australia it is now recognized that significant morbidity and mortality are associated with hospitalization (McLWilson, in Wilson 2001a) emphasising the importance of delivering health services in the most appropriate setting. Information systems for healthcare have been available for some decades. However, the lack of the adoption of such systems by healthcare workers around the world has limited the realisation of benefits of health ICT and leaves healthcare exposed to problems associated with paper-based exchanges, hand-writing, lack of integration of information and limited availability and capture of information at the point-of-care (Soar and Yu, 2002). A key factor in the lack of adoption of these systems is that they are normally designed for desk-based users whereas many healthcare workers are highly mobil (Burgess and Cooper, 2001). The new technologies of hand-held devices (note-books, PDAs and tablets), Bluetooth, 802.11 wireless and broadband CDMA/3G are changing this. According to Versel (2002), PDAs appear to be the driving force behind the increase rate of adoption of ICT by healthcare workers. There is however, a multiplicity of issues that need to be resolved before healthcare can take full advantage of these innovations. Issues that need addressing include the development of models and principles as well as specific software application solutions such as: •
Generic software for use by healthcare workers at the point-of-care.
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Interface software for point-of-care access to databases, knowledge-repositories and directories.
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Security, authentication and privacy solutions including policies.
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Clinical work-practice and organisational change guidelines.
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Communication technologies interface issues.
3. AIMS AND OBJECTIVES The aims of this project are to develop information access applications at point-of-care for the Ambulatory Care Service and demonstrate a prototype PDA based delivery system that utilises generic, reusable and scalable components. In order to facilitate optimum clinical outcomes this ehealth initiative should: •
Be easy to use and integrated with work-practices
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Be used at the point-of-care
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Provide a “push” of information to the healthcare providers to minimise time searching for information for decision-making.
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Provide reusable and scalable components
Integral to project aims are the project objectives. These are listed below and are addressed later in this paper: •
Analyse workflows in Ambulatory Care Services and produce detailed workflow diagrams.
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Create an ambulatory care information system (ACIS) to replace paper and other based systems.
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Integrate the new system into a PDA solution.
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Build a demonstrator model of the point-of-care application.
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Trial the new system.
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Analyse the results.
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Evaluate the system.
4. SIGNIFICANCE OF THIS RESEARCH The national health information strategy, Health Online, is providing national leadership for approaches to address the quality and availability of information to assist in the planning and delivery of care. The production of a model for ACIS will provide a showcase to demonstrate the anticipated benefits of point-of-care information access are beneficial and realisable. The outcome of this project will enable more timely and effective information access and management, freeing up nurses from paper work and allowing more time for consultation as has been experienced by nursing staff elsewhere (American Health Consultant, 2002). The aim of the project is to improve the design, delivery and uptake of ambulatory care services. A direct outcome from this will be a reduction in the admissions, or possible re-admissions, of patients to hospital as well as a reduction in return visits of ambulatory care providers. The integration of the latest wireless telecommunications technologies with personal digital assistants and scalable, re-usable object oriented software components in the healthcare delivery arena represents a significant innovation. It is expected that once an infrastructure is built for Ambulatory Care Services, the technologies and experiences can be applied across the full range of health specialties. This will be achieved through the use of CBSE (component-based software engineering) methodology. Increasingly, application development projects are faced with “creep” from many areas, including technology and architectures, and most importantly “data creep” (the need to make data more available, to more users, by more interfaces) (Brereton et al., 2000). Having recognized this, there is a growing trend to develop software as a set of autonomous but co-operating service oriented components that can be used as building blocks in the construction of software applications. The most obvious reason for the adoption of this layered approach is the rapid rate of technology change, allowing developers to “plug in” new technology modules as they become available. Existing projects involving PDAs at POC have all been one-off designs aimed specifically at local needs (District Nursing Service Melbourne, Plunkett NZ). To date none of these projects have addressed the issue of the design of generic components that will be reusable and scalable in other healthcare settings. With both the NSW State and Federal Governments moving to Unique Patient Identifier (UPI) and Electronic Health Record (EHR) (NSW Health Information Management and IT Strategic Plan, 2001; Health Online, 2001) there is a need for a uniform or standardized approach to development, so that innovative developments in the use of PDAs by healthcare providers will be compatible with the State and Federal requirements. The development of an ambulatory care information system (ACIS) will provide an infrastructure for the inclusion of value-added information services such as: •
Provision of convenient and easy access to accurate, timely, patient information
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User-friendly interface design and implementation
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A unique characteristic of ACIS is its access to information available to the ambulatory care providers at the point-of-care. This will include access to such things as: o
Patient care plans
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Daily Schedules
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Minimal data sets
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Data entry at point-of-care for updating main patient database
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A portable information library
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Image transmission
Interfaces to the above data repositories will be developed according to the current standards such as HL7 (including Pathology Messages Standard AS 4700.2 and Patient Administration Standard AS 4700.1), NSW Health’s Health Records and Information Privacy Bill 2001, Health Information Security Management Implementation Guide to AS/NZS 17799 (Draft, Standard Australia) and other health system development guidelines and guidelines to State and Government projects. 5. RESEARCH CHALLENGES This project contains both software engineering challenges and research opportunities. The research questions that will need answering are listed below. 1. What is the optimum workflow model to fully benefit from PDAs at the POC? 2. Is there a trade-off between the requirements, design and prototyping of the system? 3. How do we ensure that each patient and healthcare worker has a unique identifier? 4. How do we ensure the privacy, security and confidentiality of patient information? 5. What data collection protocols and techniques are appropriate to the task, and are comfortable, quick and efficient for busy healthcare workers? 6. What is the best way to implement consent and access control? 7. How do we ensure data quality and control of information storage, retrieval and secondary usage of data? 8. What are the most appropriate standards for both representation of information (classification and coding) and for communication and interconnection? 9. What is the best way to integrate all of the components into a PDA solution? 10. How should the organisation change incurred by changing work practices be managed? 11. What is the most appropriate way to evaluate the system once it has been implemented? The research questions/hypotheses and deliverables for each of these questions are contained below. 5.1 Workflow Analysis and System Design ( Questions 1, 2 and 8) Workflow analysis is a key factor for a successful definition of user needs and requirements (Kirwan & Ainsworth, 1992). An emerging view in cognitive ergonomics stresses the role of distributed cognition in work analysis. The fundamental assumption in approaches to HAV is that “human activity cannot be studied with out considering the tools involved in the activity since human work and the artefacts (ie tools, machines, rules, models) people use to accomplish tasks are inseparable woven together.” (Mancini et al., 2002, p 1.) The requirements for new artefacts are defined by the analysis of the tasks people engage in and those they wish to engage in, known as task analysis. The development of new artefacts presents new opportunities for human activities as well as new ways of undertaking existing tasks. Conversely they may also introduce new complexities, changed interactions among tasks and new difficulties and challengers for users (Mancini et al, 2002). Within this paradigm the project will use workflow and task analysis methodologies.
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During workflow and task analysis special attention will be given to different perspectives and expectations, to issues such as patient registration, clinical records and notes, patient care plans, and access to reports, patient correspondence, appointment management and communications. The analysis undertaken will be based on observation, interview and discussion with focus groups consisting of Ambulatory Care Service providers, administrative staff and patients. The development of a workflow model in return can help the Ambulatory Care Service providers reflect on what the best practice is in their daily routine work, what is the best approach and how to improve efficiency. Therefore, the establishing of a workflow model can lead to improved work practice and care. The workflow analysis will also guide the development of the system requirements. The deliverable here will be a workflow model based on feedback from all interested parties that takes into account the necessary privacy provisions of the patients as well as the design requirements of the system. 5.2 Development of Ambulatory Care Information System (Questions 3, 5-8) Development of the ACIS and interface application will be undertaken using Agile programming methodology. It is a label given to a growing number of methodologies and includes RAD (Rapid Application Development) (Radding, 2002). This new program development methodology is also suitable for web-based systems. These methodologies are called adaptive because they react to changing user requirements and agile as they allow for frequent iterations and continual testing. They are also characterised by small development teams made up of both developers and users and are suitable for prototyping. RAD prototyping is particularly suitable for applications that are highly interactive (Benyon-Davies et al, 1999). The expected deliverable here are a set of data collection, retrieval and display protocols that provide quick, convenient and secure access to unique patient information. 5.3 Ensuring Privacy, Security and Confidentiality (Question 4) To ensure the system is secure and privacy and confidentiality issues are addressed, the design of ACIS will incorporate risk assessment methods used in software engineering (Dorofee et al., 1996). Particular attention will be given to the recently released draft Federal and NSW health data privacy legislation (NSW Privacy Commissioner, 2002; Australian Department of Health and Ageing, 2002) to ensure the system complies with this legislation. (Cooper & Miller 1997, Alcock et al ,2001) The deliverable here will be systems and protocols that ensure the security of wireless communications and patient records in the event of PDA loss or theft. 5.4 PDA Integration (Question 9) The integration of the new system into a PDA solution will be accomplished through the use of component-based autonomous service objects utilising a component-based software engineering (CSBE) methodology (Atkinson et al., 2000). A component is typically independent of platform or language and may be a single object or multiple objects operating in synergy to form a complete application. The use of CBSE promotes the use and re-use of self-contained objects, facilitating the development of a system that can be implemented across a range of mobile healthcare applications. CBSE has been used for the development of web based applications but not for the development of PDA applications. The deliverables here will be an integrated PDA based POC system as well as a development framework for PDA applications based on the CSBE methodology.
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5.5 Evaluation of the System (Question 10 and 11) The system will be evaluated by adapting the “Evaluation Model for Point of Care Clinical Systems” (Westbrook & Gosling, 2003). The premise of this model is to examine the extent to which goals have been achieved in terms of 2 core measures: a) Measure technical system performance, time units, adherence to care plans, usability, functionality, and reliability issues b) Measures of social-cultural and organizational factors, which may be barriers and enablers to the achievement of goals, both from the patient and nurses aspect. In order to measure changes in ambulatory care service delivery that may be attributed to the introduction of an information system (ACIS), the proposed evaluation model will consist of pre-post ACIS implementation design. This requires measurements to be made prior to the system implementation, during implementation and then post implementation. The pre-implementation stage is crucial in obtaining baseline data against which to compare future performance. Evaluation techniques might include interviews and focus groups or observational studies to assess specific work processes and practices. During the implementation process evaluation activities will focus on the change model being adopted and how this is being operationalised. Data collected will be primarily qualitative such as interviews, focus groups and ethnographic studies. This enables a rich and detailed understanding of contextual factors affecting implementation to be gained. Post implementation measures include the continuation of pre-implementation indicators. In addition, indicators relating to technical details will be introduced. Interviews and focus groups will be aimed at evaluating the success of ACIS implementation, including end-user satisfaction and post levels of perceived ease of use, usefulness, impact on workflow and global attitudes toward ACIS. Data analysis will focus on descriptive analysis, comparison of datasets, and examination of associations between indicators. The deliverable here will be a quantitative assessment of the impact on the introduction of ACIS with strategies to manage organisational change. An evaluation of the efficacy of the system is also an expected deliverable. Should time permit, it would be desirable to use the feedback from the evaluation study to iterate those aspects of the system that may not work effectively. 6. WORK TO DATE As indicated above, an essential first step for this project will be the development of a workflow model. A detailed analysis of workflow practices has already begun , working in conjunction with Ambulatory Care Services in a la rge regional Area Health Service. Workflow diagrams have been produced for five key workflows in the existing system. Tentative models for integration of PDA based systems might be integrated have been drafted. However, it is recognised that any system development will be an iterative process. Continuing consultation with health care staff involved in work practices will be essential. 7. CONCLUSION This research into PDA applications for ambulatory care has attracted significant interest and support from two major Area Health Services. Ambulatory care staff have identified important benefits in participating in this project, among them: a more efficient in workflow / operational system. When research and development are completed, trialing and evaluation will be conducted over a number of centres. It is expected that once an infrastructure is built for Ambulatory Care Services the technologies and experiences can be applied across the full range of health specialties.
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